Written by Clay Smith
This week on one of my favorite podcasts, Hidden Brain, the host, Shankar Vedantam presented something I had never considered in education. I highly recommend you listen to this podcast for yourself. I will briefly summarize, because this could have a profound impact on those we teach in Emergency Medicine.
Noise in Our Heads
When it comes to education, some of the loudest voices are in our own heads.
"Can I do this?"
"Do I look stupid?"
"What does the professor think of me?"
"Will I fail?"
"Will I embarrass myself?"
"I'm not good at math, spelling, suturing, knitting, intubation, ________."
"If I screw this up in real life, someone dies."
"I can't take this pressure."
How can we quiet some of this noise?
To train dolphins, a behavior is paired with an offering of food. This is then paired with a clicker sound. Then the food is dropped, and the click sound is retained; yet the dolphins still feel the same positive reinforcement with just the click.
Train people like dolphins?
Surprisingly, yes -- Dr. Martin Levy at the Montefiore orthopedic surgery residency is already using operant learning theory with great success. When the instructing surgeon sees the correct surgical technique in the learning lab, he simply clicks a clicker. But how is that helpful? It's not paired with food or other positive stimulus. Or is it? The "click" is merely a non-emotional way to affirm the learner has done the task right. The positive feedback occurs when the learner gets the pleasure and satisfaction of successfully and correctly completing the task. Although as it gets nearer to lunchtime as I write this, I wonder if tossing the resident a chicken nugget could be powerfully effective as well. It’s important to acknowledge that Skinner’s method of operant conditioning has been around for decades. So this is something educators have known about and used for a long time. We are clearly late to the game. But I had never thought of applying it to medical education in this way.
Think of the alternative
What do we often do now? When one learner picks up a skill easily, we tersely say "good." When another learner seriously struggles, we may become frustrated and give negative, shaming feedback. On the other hand, we may effusively give praise once they finally accomplish the task correctly. The learner who easily mastered the skill feels shortchanged, and the one who had difficulty may begin to focus on praise or shame from the instructor. This doesn't quiet the voices in the learner's mind; it amplifies them. Do we want our trainees to merely work for our praise or to avoid our shaming? Emphatically, we do not. We want them to become expert clinicians and take excellent care of patients. Our job as the teacher is to get them there. So if we can extricate ourselves from the learner's mind and reduce the emotional baggage we put on the learner, they can simply focus on the task. Their reward isn't our praise; it is expertly doing the task. There is no shame in failing. They just try again. We don't let out an exasperated, "Have you even been listening? Worst resident ever!" Rather, there is no click when the task is completed incorrectly, and a click when it is done right.
Do I really want to click at my residents?
I'm not sure I want to carry around a clicker and click for good resident behavior. What I take away is to reduce the emotional garbage I drag into the learning environment. Letting the learner know up front that if they do it wrong in the learning environment, that is not failure; I could just say unemotionally, "Try again." And when they do it right, I could just say, "Yes." This would work especially well for task-oriented learning, like procedure lab or ultrasound training.
Listen to this!
Again, I want to reiterate that this was an incredibly insightful and helpful podcast for us as medical educators. I would strongly encourage you to listen to the whole podcast. It is told much better than this synopsis and provides much more detail.
If you comment, I will click and feed you a fish.
If you have thoughts on this, would you please leave a comment on the website, located below the blog post, or on social media? Are you using operant methods already? Does it work? How could we do this without using a clicker? Or is a clicker the best way? How about a large gong when they fail (...kidding)? Anyway, you get the idea. Comments and discussion would be particularly helpful on this topic.